Report of an unusual cause of rhinolithiasis: an 'opioma'.

Abstract

We report an unusual case of unilateral rhinolith. The patient was a 21-year-old man who had a history of left-sided nasal obstruction and recurrent bouts of fetid, purulent rhinorrhea of several years' duration. The rhinolith, which had formed around an impacted foreign body, was extracted in several pieces under local anesthesia. Laboratory evaluation revealed that the foreign body was a hardened mixture of codeine and opium wrapped in a small sheet of nylon--what we called an "opioma."

Introduction

Rhinoliths are benign calcareous concretions that develop as a result of the deposition of salts on an intranasal foreign body. (1) Rhinoliths grow slowly and may go unnoticed for years. (2,3) When symptoms of rhinolithiasis do occur, they can range from a slight unilateral nasal discharge or obstruction to marked structural changes, depending on how long the mass has been present. (1,4)

Although rhinoliths are rare, an understanding of this entity will allow physicians to distinguish this type of mass from others in the nasal cavity should they ever encounter such a case. (5) We report an unusual case of rhinolithiasis, and we briefly review the characteristics of this entity.

Case report

A 2l-year-old man, a foreign visitor to Iran, presented with a history of left-sided nasal obstruction and recurrent bouts of fetid, purulent rhinorrhea of several years' duration. Clinical examination revealed that the patient was a mouth breather with hyponasal speech. No outwardly visible facial deformity was evident.

Anterior rhinoscopy of the right nasal chamber revealed a right septal deviation but no other significant pathology. Rhinoscopy of the left nasal chamber revealed a profuse, fetid discharge and a mass in the posterior portion of the nasal fossa. Conventional x-rays also showed a radiopaque mass on the left (figure 1) and the mild septal deviation on the right.

[FIGURE 1 OMITTED]

The rhinolith was extracted in several pieces under local anesthesia (figure 2). Inspection of the remnants revealed that the contents of the mass had been wrapped in a nylon sheet. The contents were sent to a reference laboratory for identification. Following the procedure, plain x-rays revealed no complications of the rhinolith or its removal.

[FIGURE 2 OMITTED]

A reference laboratory identified the contents of the rhinolith as a mixture of codeine and opium, which we called an opioma. (2) The patient had earlier denied drug addiction and drug smuggling. It is possible that he had hidden the drugs in his nose for some reason and forgotten that they were there.

Discussion

Rhinoliths are classified as exogenous and endogenous. (6) Exogenous rhinoliths can form around almost any kind of substance or item small enough to be inserted into the nose, including seeds, fruit pits, pieces of food, pebbles, dirt, cloth, pieces of wood, buttons, paper, sand, glass, jewelry, plastic, and many others. (3,5,6-14)

The route of entry is usually anterior, although some foreign bodies have been reported to have entered through the choana during vomiting or coughing. (8-10,13) Foreign bodies are often placed in the nasal cavity during childhood, (1) usually by the child or a playmate. (2) Symptoms at the time of the insertion are usually minor, and the patient may forget the event. A latent period of variable length follows, during which time the rhinolith develops and enlarges. (l,2,14) The physician should have a high index of suspicion for a diagnosis of rhinolithiasis in a patient with a densely mineralized lesion that appears to be benign and is not associated with bone destruction. (2,3,5,10,14,15) Removal is usually accomplished through the anterior nares, with or without general anesthesia.

Illegal drugs can be wrapped in a piece of plastic or other material and inserted into the nose for purposes of hiding or smuggling the drug. If the wrapping is not made of a suitable material or if it is damaged or accidentally ingested, the patient may develop symptoms of opium overdose, regardless of whether the patient is an opium addict. Therefore, a high index of suspicion should also be maintained for the presence of a drug-containing foreign object in the nasal cavity of a nonaddict who experiences a drug overdose.

References

(1.) Poison CJ. On rhinoliths. J Laryngol Otol 1943;58:79-116.

(2.) Appleton SS, Kimbrough RE, Engstrom HM. Rhinolithiasis: A review. Oral Surg Oral Med Oral Pathol 1988;65:693-8.

(3.) Hadi U, Ghossaini S, Zaytoun G. Rhinolithiasis: A forgotten entity. Otolaryngol Head Neck Surg 2002;126:48-51.

(4.) Price HI, Batnitzky S, Karlin CA, Norris CW. Giant nasal rhinolith. AJNR Am J Neuroradiol 1981;2:371-3.

(5.) Royal SA, Gardner RE. Rhinolithiasis: An unusual pediatric nasal mass. Pediatr Radiol 1998;28:54-5.

(6.) Eliachar I, Schalit M. Rhinolithiasis. Report of eight cases. Arch Otolaryngol 1970;91:88-90.

(7.) Ballenger JJ. Diseases of the Nose, Throat, Ear, Head, and Neck. 14th ed. Philadelphia: Lea & Febiger; 1991:144. (8.) Harbin W, Weber AL. Rhinoliths. Ann Otol Rhinol Laryngol 1979;88:578-9.

(9.) Abdel-Latif SM, Abdel-Hady S, Moustafa HM. Crystallographic study of rhinoliths. J Laryngol Otol 1979;93:1205-9.

(10.) Meyer JR, Quint DJ. Posttraumatic rhinolith. AJNR Am J Neuroradiol 1993;14:1181-2.

(11.) Cardier HM, Hill JJ. Asymptomatic rhinolith: A brief review of the literature and case report. Laryngoscope 1966;76:524-30.

(12.) Munoz A, Pedrosa I, Villafruela M. "Eraseroma" as a cause of rhinolith: CT and MRI in a child. Neuroradiology 1997;39:824-6.

(13.) Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-Head and Neck Surgery. St. Louis: Mosby; 1998:723-5.

(14.) Aksungur EH, Binokay FB, Bicakci K, et al. A rhinolith which is mimicking a nasal benign tumor. Eur J Radiol 1999;31:53-5.

(15.)Keck T, Liener K, Strater J, Rozsasi A. Rhinolith of the nasal septum. Int J Pediatr Otorhinolaryngol 2000;53:225-8.

Hadi Ghanbari, MD; Mohammad Farhadi, MD; Ahmad Daneshi, MD

From the Department of Otolaryngology-Head and Neck Surgery, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran.

Reprint requests: Hadi Ghanbari, Department of Otolaryngology-Head and Neck Surgery, Rasoul Akram Hospital, Iran University of Medical Sciences, Sattarkhan Ave., Tehran, Iran. Phone: [phone]; fax: [phone]; e-mail: [e-mail]